Health & Education
Passport
Central CA Training Academy
559-278-5757
Terry Luna, CWS/CMS Project Coordinator
terril@csufresno.edu
Revision June 2011
Table of Contents
Legislative Cites for Health & Education Passport
Page 2/3
Creating the Health & Education Passport
Page 4
Client Notebook
Page 5
Recording Education Information
Page 6
Deleting an Education Notebook
Page 7
Using the Health Notebook
Page 8
Recording Psychotropic Medications
Page 9/10
Recording Well Child Exams – Contact Notebook
Page 11
Service Provider Search Tips
Page 12
Placement Information
Page 13
Health/Education Related Outcome Measures:
Timely Medical & Dental Exams – 5B(1) & (2)
Page 14
Psychotropic Medications – 5F
Page 15
Individualized Education Plans – 6B
Page 16
Forms:
Passport Mapping
Page 17/25
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CALIFORNIA WELFARE AND INSTITUTIONS CODE
Division 9. PUBLIC SOCIAL SERVICES
Part 4. SERVICES FOR THE CARE OF CHILDREN
Chapter 1. FOSTER CARE PLACEMENT
§ 16010.
a) When a child is placed in foster care, the case plan for
each child recommended pursuant to Section 358.1 shall include a
summary of the health and education information or records,
including mental health information or records, of the child. The
summary may be maintained in the form of a health and education
passport, or a comparable format designed by the child protective
agency. The health and education summary shall include, but not
be limited to, the names and addresses of the child's health,
dental, and education providers, the child's grade level
performance, the child's school record, assurances that the
child's placement in foster care takes into account proximity to
the school in which the child is enrolled at the time of
placement, the number of school transfers the child has already
experienced, the child's educational progress, as demonstrated by
factors, including, but not limited to, academic proficiency
scores, credits earned toward graduation, a record of the child's
immunizations and allergies, the child's known medical problems,
the child's current medications, past health problems and
hospitalizations, a record of the child's relevant mental health
history, the child's known mental health condition and
medications, and any other relevant mental health, dental,
health, and education information concerning the child determined
to be appropriate by the Director of Social Services. If any
other law imposes more stringent information requirements, then
that section shall prevail.
DIVISION 31 REQUIREMENTS (31-200 & 400)
31-206.35
For children receiving out-of-home care, the social worker shall
document in the case plan, the following:
Health and Education Information about the Child:
 Names and Addresses of the child’s health and education
providers.
 Child’s grade level performance.
 Child’s school record.
 Assurances that the child’s placement in foster care takes
into account proximity to the school in which the child is
enrolled at the time of placement.
 A record of the child’s immunizations.
 The child’s known medical problems.
 The child’s medications.
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If any of the required health and education information is not
contained in the case plan, the case plan shall document where
the information is located.
31-206.361
Each child in placement shall receive a medical and dental
examination, preferably prior to, but not later than, 30 calendar
days after placement.
31-405.1
(m)
Ensure that information regarding available CHDP services is
provided to the out of home care provider within 30 days of the
date of the placement.
(n)
Ensure that the child receives medical and dental care which
places attention on preventive health services through the Child
Health and Disability Prevention (CHDP) program, or equivalent
preventive health services in accordance with the CHDP program’s
schedule for periodic health assessment.
(1) Each child in placement shall receive a medical and
dental examination, preferably prior to, but not later
than, 30 calendar days after placement.
(o)
Make certain that arrangements for, and monitoring of, the
child’s educational progress while in placement are undertaken.
(s)
Provide the out-of-home care provider the child’s background
information as available, including, but not limited to, the
following histories:
 Educational
 Medical
 Placement
 Family
 Behavioral
(q)
Provide the out-of-home care provider(s) information of any known
or suspected dangerous behavior of the child being placed.
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CREATING THE HEALTH & EDUCATION PASSPORT
The Health & Education Passport is populated from several Notebooks throughout
CWS/CMS. Information cannot be entered directly onto the Passport.
Client Notebook – several pages of this notebook populate the passport with basic
child information. The ‘service provider’ page will populate past and present
health service providers of the child.
Education Notebook – this notebook populates the passport with past and present
educational information for the child.
Health Notebook – this notebook populates the passport with all relevant health
history for a child, including ‘diagnosed conditions’, ‘medications’,
‘hospitalizations’, ‘immunizations’, etc.
Contact Notebook – The Associated Services page of the contact notebook must
be used to document CHDP – Physical & Dental information. Only Well Child
exams with an HEP indicator will populate to the passport.
Placement Notebook – Use the ID page of this notebook to document the ‘date
SCP informed of the CHDP program and that brochure was given’; if ‘SCP
requests CHDP services’; and ‘date SCP was given the HEP and informed of it’s
purpose’.
Use the ID page to note that Social Worker considered proximity to the school in which
the child was enrolled at time of placement.
Use the ‘Create New Document-Client’ Notebook to generate the Passport.
Select the Time Frame parameters from the next dialog box.
This will create the Passport in Microsoft Word. It can be Saved and Printed, but
CANNOT be edited! Any changes must be made in the Notebooks, then the
passport can be removed – and re-created. There can only be ONE passport per
child. The passport can be continually refreshed, by removing it and recreating
it.
SAVE TO DATABASE
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CLIENT NOTEBOOK
Areas in GREEN are important to complete for Passport.
Enter basic identifying client information here, DOB, SS, ethnicity and language. If child
is in placement, be sure to check the confidentiality in effect box.
Enter basic demographic information for the client, birthplace, arrests, etc.
Record all address changes here. Be sure to enter start and end dates for addresses.
NOTE: this is NOT the place to change an address for a child in placement or when a
foster parent or relative caregiver moves.
Enter any other names or AKA’s that your client may use. This will cross-reference all
names when a client search is done.
Relate all clients to each other on this page. Be sure that the relationship is in the correct
order as they are listed or they will populate incorrectly to many documents that
CWS/CMS produces.
This page is where the county case number is entered. It is important that the number be
active (no end date), if this is a child that a placement will be recorded for. Other types
of numbers can be entered here for clients, for example, CII, MEDS Id, etc.
Juvenile court numbers are entered on this page for children only.
Parent search information is recorded on this page. Record searches information in the
parent’s notebook. Search results entered here will populate to the Declaration of Due
Diligence.
Eligibility information to Foster Care is recorded on this page.
Once an attorney has been appointed on behalf of a client, they must be attached on this
page.
Use this page to show service providers involved with client. Use the plus + sign to add
service provider. Service providers with no END date – will populate Current Service
Provider section of passport. Providers with END date entered populate the ‘past
provider’ section. Only Providers that have been used in a Contact will appear under the
plus. Use the Search option to located Providers that are not in the list.
This page records information about a child’s Indian status – it must be completed before
ICWA notices can be generated from CWS/CMS.
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QUICK GUIDE TO THE EDUCATION NOTEBOOK
There should only be ONE notebook per school the child has attended.
Record the school child is attending:
SEARCH TIPS:
Before you can record education information for
a child, you must SEARCH for the school that the
child is attending.
You must select ‘School Category’ and at least one other
identifying factor. The easiest method is to choose your
county, the under the ‘school’ drop down, all schools in
your county will appear – then select the one you want
from the list.
Create New Education
After using the plus button – to Create New
Education notebook for a child:
Highlight the child’s name you want to place
in school, then highlight the school child is
attending. Click OK.
Use this page to record the date the child began
attending this school.
Use this page to record child’s grade level and
attendance records, progress, report cards, IEP,
associated with that grade level.
Always use the plus button (+) to add history
for each grade level.
SAVE TO DATABASE
Once the child has been recorded as attending school, additional information gathered at each
contact can be recorded in the child’s ‘Existing Education Notebook’.
Open the child’s existing education notebook
in order to add additional education
information.
Use the appropriate page to record the
information you have gathered.
SAVE TO DATABASE
Open the child’s existing education notebook,
and record the end date and reason child is no
longer attending this school.
Remove a child from school:
SAVE TO DATABASE
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Deleting an Education Notebook (if entered by mistake)
Open the Education Notebook that you want to remove – and go to
the Education Record Page.
Remove all rows from the page – highlight row, and use the delete
key.
All rows must be deleted from this page.
Then open ‘Existing Education Notebook’:
The remove button should be available.
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HEALTH NOTEBOOK
Use this page to summarize a child’s current condition. When a new Summary
is entered, the old Summary is erased. It will only remain on a hard copy of the
previous HEP. This Summary does NOT keep history. Has the child been
clinically diagnosed by a qualified professional as having at least one of the
following disabilities: mental retardation; visually or hearing impaired;
physically disabled; emotionally disturbed, or other medically diagnosed
conditions requiring special care.
Use this page to record any conditions a child has which are diagnosed by a
practitioner or a clinic. Record as much information about the condition as
possible. Use start and end dates to document child’s health history. If an alert
is checked, the condition will populate to first page of Passport.
Use this page to record any conditions a child may have that have been observed
by someone. Record as much information about the condition as possible. Use
start and end dates to document child’s health history. Observed conditions will
only print to passport if the alert is checked.
Use this page to document any medications prescribed for a child. Each
medication must be tied to a ‘Client Condition’ (which comes from the
‘Diagnosed Conditions’ page.)
Hospitalizations
Use this page to document anytime a child has been hospitalized. The
hospitalization must be tied to a ‘Client Condition’.
Medical Tests
Use this page to document any medical tests ordered for a child and those test
results. The medical tests must be associated with a ‘Client Condition’.
Referrals
Use this page to document any medical referrals made on behalf of a child by a
Health Provider. The referrals must be associated with a ‘Client Condition’.
Use this page to document a child’s immunization history.
Well Child
Use this page to record information regarding a child’s Well Child exam. You
must enter a Well Child Exam as an Associated Service in the Contact Notebook
PRIOR to completion of the information on this page.
Birth History
Use this page to enter birth history information for a child. This is also a good
place to record a toxicology screening. Certain information on this page is
duplicated on the Demographic page of the client notebook. The information
will cross populate each notebook.
SAVE TO DATABASE
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RECORDING PSYCHOTROPIC MEDICATIONS IN THE HEALTH NOTEBOOK
Outcome Measure 5F
Open the child’s Health Notebook and use the Diagnosed Conditions &
Medications Pages:
DIAGNOSED CONDITION Page:
 Onset Date:
Date condition was diagnosed by practitioner. This could be before or after child
entered foster care.
 Condition – Health Problem:
Choose the most appropriate health problem, avoid using Psychotropic
Medication required.
 Health Problem Description:
Add the condition as written on the JV220.
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MEDICATIONS Page:
One medication per line:
 Prescribed Medication is attached to the diagnosed condition it has been
prescribed for.
 Prescribed By: enter the doctor that prescribed the medication.
 Start date – with NO end date indicates current medication. Use the actual date
child begins taking the medication.
 Projected End Date: Date the court order expires (should be 6 months/180 days
from date of current court order).
 End Date: Only use this to record a medication that the child is no longer taking.
 Court Ordered Date: Date the JV220 is signed by the judge. Update this date as
new court order is signed for current medication – add a new row with new date.
 Comment/Instructions:
o Date each entry
o List the dosage or range
o List alternative medications listed on the JV220 that may be given in the
future
o If medication is same, but new doctor – note here and Prescribed By field.
 Check appropriate radio buttons if the medication is ‘psychotropic’ and if
administered for ‘psychiatric purposes’.
 An ‘automatic reminder’ will be generated from the court order date or if no date
has been entered.
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QUICK GUIDE TO RECORDING CONTACTS & SERVICES
Use the Contact Notebook to record every
contact (narrative) that is made on behalf of a
child. If more than one child is selected – then
that narrative will go to all selected children’s
cases.
Be sure to complete all YELLOW fields.
Create New Contact:
Use the ‘Spell Check’ command under the
Edit menu once narrative has been entered.
RECORD A CASE MANAGEMENT SERVICE
WITHIN THIS CONTACT:
RECORD SERVICES BEING PROVIDED ON
BEHALF OF A CHILD/FAMILY:
If Social Worker provided any type of a case
management service for child or family, be
sure to select service type under ‘Case
Management Service Type’.
This will complete the Associated Services
page, and Social Worker can add narrative
entry to this page.
Open ANY existing contact or complete a
NEW contact, then click on the Associated
Services page.
Use the plus button in the upper left corner to
add each Service provided to child/family.
Be sure to complete all YELLOW fields.
If you are unable to find the Service Provider
in search, go to the next step: Create New
Service Provider.
CREATE NEW SERVICE PROVIDER:
,
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The ‘Well Child Exam’ button will become
enabled ONLY if the following services are
selected:
HEP – CHDP Equivalent Physical Exam
HEP - CHDP Physical Exam
HEP - Required Dental Exam
A Well Child Exam can be recorded for ONLY
one child at a time.
**Only create a service provider, if you were
unable to locate provider using SEARCH.**
Complete both pages with as much information
as you can.
Be sure to complete all YELLOW fields.
11
SERVICE PROVIDER SEARCH Tips:
Most service providers are already in the database, the trick is finding them.
You can search with provider’s first and last name, or agency name, or any
combination. There is no phonetic search – that means that your spelling has to be
just right, or you will not find the provider.
You can search using City or Zip Code to narrow the search.
Only the first 50 providers will be displayed in the Search, but there will be a
message telling you there are more than 50. You must enter additional search
parameters in order to view more.
Use the ‘Wild Card’ for additional search power.
Example: Searching for the provider: Financial First
Surrounding the word ‘financial’ with the percent signs – is asking
for any provider with the word financial in it.
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PLACEMENT NOTEBOOK
Open the Existing Placement:
Record the ‘Date the Substitute Care Provider was informed of the CHDP
program and the brochure was given.
If the Substitute Care Provider requests CHDP services be provided, check
the box indicating so.
Document the Date the Substitute Care Provider was given the Health and
Education Passport, and informed of it’s purpose.
Rationale section:
Use this page to document that the child’s placement in foster care takes
into account proximity to the school in which the child was enrolled at the
time of placement and whether or not the child attends the same school as
prior to the placement.
SAVE TO DATABASE
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Timely Medical and Dental Exams
State Measure – 5B(1) and 5B(2)
This measure provides the percent of children meeting the schedule for CHDP/Division
31 medical and dental exams. Minors must have a medical and/or dental exam by the
end of their age period.
CWS/CMS
Child must be in placement and episode open 31 days or more.
Placement home is in California.
Minor’s age taken at quarter end.
Excludes:
Non-CWD placements (probation, etc)
Placement episodes open less than 31 days
Children in placement homes outside of CA
Runaways
Non-foster care placements
Non dependent Legal Guardians
Contact Notebook:
A ‘delivered service’ must be recorded in the contact notebook on the Associated
Services page of:
Use these types only:
CHDP Medical Exams
CHDP Dental Exams
Health/CHDP Services
CHDP Dental Delivered
CHDP Medical Delivered
HEP-Periodic Dental Exam
HEP-CHDP Equivalent Physical Exam
HEP-CHDP Physical Exam
Medical Assessments-Age Exam Categories
Under 1 month
1 to 2 months
3 to 4 months
5 to 6 months
7 to 9 months
10 to 12 months
13 to 15 months
16 to 23 months
2 years
3 years
4 to 5 years
6 to 8 years
9 to 12 years
13 to 16 years
17 to 20 years
Dental Assessments
3 years and once a year thereafter till age 20
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Authorization of Psychotropic Medications
State Measure – 5F
This measure provides the percent of children in foster care with a court order or parental
consent that authorizes the child to receive psychotropic medication.
CWS/CMS
ID page: Agency Responsibility is County Welfare Agency
Includes:
 Placement Episode Open or Closed during the quarter
 Placement open or Closed during the quarter
 Outgoing ICPC placements
 Runaways or Closed Placement w/Open Episode
Excludes:
 All non child welfare agency placements (probation, other)
 All placements with Legal Authorization codes other than WIC a-j, e, h, 601 &
602
 Incoming ICPC placements
 Non-foster care placements
 Non Dependent Legal Guardians
 Children in Placement Facility Type – Guardian home
One medication listed on this page must be Active – no end date. Or the medication must
have been active during the review period. A Psychotropic Medication consent date must
have occurred prior to the last day of the review period – either Court Order or Parental
Consent date.
No end
date
Parental
Consent/Court Order
date here
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Individualized Education Plan (IEP)
State Measure – 6B
This measure provides the percentage of children in out-of-home (OHP) placements who
have ever had an IEP.
CWS/CMS




Child must have an open case.
Child must be in placement.
Placement episode must be 31 days or longer.
Child must be placed in California.
Exclude:
 Non-dependent legal guardianship placements.
 ICPC placements (in or out).
 Children younger than 3 years old.
 Children who turned 3 years old 31 days or less before the end of the quarter.
 Children 19 years of age or older.
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Heath & Education Passport Mapping
The Health & Education Passport is a protected document –
it cannot be changed or modified in Microsoft WORD.
Use the Mapping on the following pages to determine the
notebooks, pages and fields in CWS/CMS that populate to
each section of the Health Passport. Each section is color
coded to indicate which section in CWS/CMS each notebook
is found.
Once changes have been made in CWS/CMS – Save to
Database – then remove the ‘OLD’ Passport and recreate a
‘NEW’ Passport. The Passport will be refreshed with the
new information added in the CWS/CMS Screens.
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Confidential
Health
and
Education
Passport
Instructions to Foster Parents
Please keep this Health and Education Passport while this child is in your care. Please keep the child’s MediCal card, health eligibility identification cards, Medical Consent form, Birth Certificate and Immunization record with
this Passport.
Take this Passport to all medical, dental, and educational visits pertaining to the child. Remind doctors,
dentists, and teachers, mental health care providers, vision care providers, and other health care providers to add or
correct information on the form after each visit. Please give the corrected Passport to the social worker at your next
meeting. When the child leaves your care, the latest update of this Passport will go with the child to aid the next care
provider.
If you have any questions, please speak with the child’s social worker and/or Public Health Nurse.
Thank you.
State of California Health and Welfare Agency
Department of Social Services
CWS Case Management System
CP-OHCHEP REV (08/2010)
HEALTH AND EDUCATION PASSPORT
May 30, 2016
Confidential in accordance with
Penal Code Section 11167.5 and/or
WIC Sections 827 and 10850
Page 1 of 25
CHILD INFORMATION
CHILD’S NAME
Client Notebook – ID Page
NAME ALSO KNOWN BY
Client Notebook – Names Page
CASE NUMBER
Case Information notebook-ID
page
BIRTH DATE
Client Notebook
– ID Page
CHILD ID NUMBER
Client Notebook – ID Page
MEDI-CAL
RECORD
NUMBER
Client Notebook
– ID Num Page
(Medical Record)
AGE
GENDER
Client
Client
Notebook Notebook –
– ID Page ID Page
COURT NUMBER
Client Notebook – Juvenile Court Number
Page
MEDICAL INSURANCE COMPANY NAME / HMO
POLICY NUMBER
FC-2 Eligibility Application NB – FC-2 Eligibility
Application NB –
Insurance Page
ADDRESS
If Child is in Placement – “Confidential Address” should appear here.
Client Notebook, ID page – checkmark in “Confidentiality in Effect”
ETHNICITY
Client Notebook – ID Page
PRIMARY LANGUAGE
Client Notebook – ID Page
NAME OF SUBSTITUTE CARE PROVIDER
If Child is in Placement – “Confidential Name” will
appear here
SCHOOL NAME
Education Provider-ID page- the school name will
populate for the school that has a start date – and
no end date.
Insurance Page
SOCIAL SECURITY NUMBER
Client notebook-ID page – Will NOT
populated even if entered
PHONE
Client notebook-Address page
RELIGION
ICWA ELIGIBILITY
Client Notebook – ID Page
Client notebookDemographics page
SECONDARY LANGUAGE
Client Notebook – ID Page
RELATIONSHIP TO CHILD OR TYPE OF FACILITY
If Child is in Placement – “Confidential Relationship” will
appear here. Client Notebook, ID page – checkmark in
“Confidentiality in Effect”
SCHOOL ADDRESS
GRADE
Education Provider-Address page
Education
notebook,
Grade
Level
Informatio
n page
PHONE
Education notebook-Grade Level Information page
CURRENT HEALTH INFORMATION
SENSITIVE HEALTH & MEDICAL INFORMATION ON FILE (Health Notebook-Summary page – Sensitive Checkbox)
LIMITATION PUT ON SUBSTITUTE CARE PROVIDER’S ABILITY TO MAKE HEALTH DECISIONS(Health NotebookSummary page)
INDIVIDUAL HEALTH CARE PLAN ON FILE FOR SPECIAL NEEDS CHILD (Health Notebook-Summary page)
State of California Health and Welfare Agency
Department of Social Services
CWS Case Management System
CP-OHCHEP REV (08/2010)
HEALTH AND EDUCATION PASSPORT
May 30, 2016
Confidential in accordance with
Penal Code Section 11167.5 and/or
WIC Sections 827 and 10850
Page 1 of 25
** ALERTS **
DESCRIPTIO
N
Health notebook, Diagnosed Condition and Medications pages (Alert box)
!@#$%(10)
ALLERGIES
DESCRIPTIO
N
Health Notebook-Diagnosed Condition (Allergies)
ONSET DATE/FIRST VISIT
Health NotebookDiagnosed Condition
!@#$%(0)
DIAGNOSED BY
Health Notebook-Diagnosed Condition
SUMMARY OF CHILD’S CURRENT HEALTH CONDITION
Health notebook, Summary page – Narrative entry from this field populates here.
DEVELOPMENTAL / FUNCTIONAL LIMITATIONS
VISUAL IMPAIRMENT
SPECIAL DIET REQUIRED
DEVELOPMENTALLY DISABLED
DEVELOPMENTALLY DELAYED
HEARING IMPAIRMENT
NEUROLOGICAL
IMPAIRMENT
NON AMBULATORY
SPECIAL EDUCATION PUPIL,
CERTIFIED
SPEECH IMPAIRMENT
MEDICAL EQUIPMENT REQUIRED
MEDICAL PROCEDURES REQUIRED
EMOTIONAL DISORDER, DSM, CURNT
REV
DESCRIPTIO
OTHER N
Health notebook-Diagnosed Condition page (choose these under Physical, Behavioral or Emotional
category)
CURRENT HEALTH ISSUES
Each Health Problem without an end date on Diagnosed Conditions Page is followed by related information from
the Health notebook-Medications, Hospitalizations, Medical Tests, and Referrals pages.
HEALTH PROBLEM
ONSET DATE/FIRST VISIT
NEXT SCHEDULED VISIT
DATE
Health notebook-Diagnosed Condition page
Health notebook-Diagnosed
Health notebook-Diagnosed
Condition page
Condition page
DIAGNOSED BY: NAME
DIAGNOSED BY: PHONE
COMMUNICABLE DISEASE?
Health notebook-Diagnosed
Condition pg
YES
NO
UNKNOWN
Health notebook-Diagnosed Condition page
Health notebook-Diagnosed
Condition pg
HEALTH PROBLEM DESCRIPTION
Health notebook-Diagnosed Condition page
TREATMENT PLAN / INSTRUCTIONS
Health notebook-Diagnosed Condition page
!@#$%(1)
WELL CHILD EXAM
DATE
EXAM TYPE
SERVICE PROVIDER
Health Notebook –
Health Notebook – Well Child Page
Health Notebook – Well Child Page
Well Child Page
(Contact notebookAssociated Services
page)
State of California Health and Welfare Agency
Department of Social Services
CWS Case Management System
CP-OHCHEP REV (11/94)
HEALTH AND EDUCATION PASSPORT
May 30, 2016
Confidential in accordance with
Penal Code Section 11167.5 and/or
WIC Sections 827 and 10850
2
AGE AT TIME OF
EXAM
Client notebook-ID
page
HEIGHT
HEIGHT %
WEIGHT
WEIGHT %
HEAD CIRCUMFERENCE
Health
Notebook –
Well Child
Page
Health
Notebook –
Well Child
Page
Health
Noteboo
k – Well
Child
Page
Health Notebook
– Well Child
Page
Health Notebook – Well
Child Page
COMMENTS / OUTCOMES / REFERRALS
Health Notebook – Well Child Page
!@#$%(2)
IMMUNIZATIONS
IMMUNIZATION TYPE DATE GIVEN OR
WAIVED
Health notebookHealth notebookImmunization page
Immunization page
WAIVED SOURCE OF INFORMATION / CLINIC /
PHYSICIAN
Health notebook-Immunization page
!@#$%(3)
NEXT DUE DATE
Health
notebookImmunization
page
CURRENT HEALTH SERVICE PROVIDERS
Health notebook-Summary page
CURRENTLY RECEIVES SERVICES
CA CHILDREN’S
REGIONAL
OTHE
FROM:
SERV
CENTER
R
SERVICE PROVIDER NAME
SERVICE PROVIDER TYPE
DATE LAST SEEN
Client notebook-Service Providers page –
Service Provider
Contact notebook-Associated
providers listed on this page with no end
notebook-ID page
Services page
date will populate here.
CLINIC/AGENCY NAME, IF ANY
ADDRESS
Service Provider notebook-ID page
PHONE
Service Provider notebook-Address page
Service Provider notebook-ID page
!@#$%(4)
PAST HEALTH INFORMATION
BIRTH PLACE / HOSPITAL NAME
Health notebook-Birth History page or
Client Notebook – Demog Page
WEIGHT
LENGTH
Health notebookBirth History page
BIRTH HISTORY
BIRTH LOCATION (CITY COUNTY STATE AND COUNTRY)
Health notebook-Birth History page or Client Notebook – Demog Page
Health notebook-Birth
History page
HEAD
CIRCUMFERENCE
Health notebookBirth History page
GESTATION
AGE
Health notebookHealth
Birth History page
notebookBirth History
page
NEWBORN SCREENING RESULTS
TOXICOLOGY SCREENING
Health notebook-Birth History page
PRENATAL / PERINATAL COMMENTS
Health notebook-Birth History page
State of California Health and Welfare Agency
Department of Social Services
CWS Case Management System
CP-OHCHEP REV (11/94)
APGAR
HEALTH AND EDUCATION PASSPORT
May 30, 2016
Confidential in accordance with
Penal Code Section 11167.5 and/or
WIC Sections 827 and 10850
3
PAST HEALTH ISSUES
Each Health Problem with an end date is followed by related information from the Health notebookMedications, Hospitalizations, Medical Tests, and Referrals pages.
HEALTH PROBLEM
ONSET DATE/FIRST VISIT
END DATE
Health notebook-Diagnosed Condition
Health notebook-Diagnosed
Health notebook-Diagnosed
page
Condition page
Condition page
DIAGNOSED BY: NAME
DIAGNOSED BY: PHONE
COMMUNICABLE DISEASE?
Health notebook-Diagnosed
Condition page
YE
NO
UNKNOWN
Health notebook-Diagnosed Condition
Health notebook-Diagnosed Condition
S
page
page
HEALTH PROBLEM DESCRIPTION
Health notebook-Diagnosed Condition page
TREATMENT
Health notebook-Diagnosed Condition page
!@#$%(5)
PAST HEALTH SERVICE PROVIDERS
Health notebook-Summary page
PREV. RECEIVED SERVICES
CA CHILDREN’S
REGIONAL
OTHE
FROM:
SERV
CENTER
R
SERVICE PROVIDER NAME
SERVICE PROVIDER TYPE
DATE LAST SEEN
Client notebook-Service Providers page –
Service Provider
Contact notebook-Associated
providers listed on this page with End Date
notebook-ID page
Services page
CLINIC/AGENCY NAME, IF ANY
ADDRESS
Service Provider notebook-ID page
Service Provider notebook-Address page
PHONE
Service Provider notebook-ID page
!@#$%(6)
FAMILY MEDICAL HISTORY
MATERNAL - SIGNIFICANT HEALTH
PROBLEMS
Health notebook - Birth History page
PATERNAL - SIGNIFICANT HEALTH
PROBLEMS
Health notebook - Birth History page
State of California Health and Welfare Agency
Department of Social Services
CWS Case Management System
CP-OHCHEP REV (11/94)
HEALTH AND EDUCATION PASSPORT
May 30, 2016
Confidential in accordance with
Penal Code Section 11167.5 and/or
WIC Sections 827 and 10850
4
EDUCATION INFORMATION
PARENT(S) / GUARDIANS EDUCATIONAL RIGHTS LIMITED?
YE
NO
S
Education notebook-Enrollment Information page or Client
Notebook-Demog Pg
COURT APPOINTED EDUCATION REPRESENTATIVE
PHONE NUMBER
Education notebook-Enrollment Information page
Education notebook-Enrollment Information page
DOES THE CHILD HAVE AN INDIVIDUALIZED
YE
NO MOST RECENT IEP
EDUCATION PROGRAM (IEP/IIFSP)?
S
DATE:
Education notebook-Grade Level Information page –
IEP recorded as an Education Record
LOCATION OF EDUCATIONAL RECORDS / ATTEMPTS TO ACQUIRE
Client notebook- Demographics page
ARE TRANSITIONAL INDEPENDENT LIVING SERVICES BEING
YE
NO
PROVIDED?
S
Case Plan notebook-Planned Client Services page – ILP Services
recorded here.
HAS THE CLIENT COMPLETED AT LEAST ONE SEMESTER OF
YE
NO
COLLEGE?
S
Education notebook-Enrollment Information page
HAS THE CLIENT ATTENDED POSTSECONDARY/VOCATIONAL
YE
NO
TRAINING?
S
Education notebook-Enrollment Information page
CLIENT SPECIAL EDUCATION
INSTRUCTION
RECEIVED?
Education notebookEnrollment
Information page
YES
!@#$%(11)
NO
START DATE
END DATE
Education
notebookEnrollment
Information page
Education notebook-Enrollment Information page
CURRENT
Education Notebook for a child completed with a start date and no end date will appear as the current school.
SCHOOL NAME
PHONE
Education Provider notebook-ID page
Education Provider notebook-ID page
SCHOOL ADDRESS:
Education Provider notebook-Address page
CONTACT NAME
START DATE
Education Provider notebook-Contact page
Education notebook-Enrollment Information page
EXPLANATION IF CHILD WAS NOT PLACED IN PROXIMITY OF PREVIOUS SCHOOL ENROLLMENT
Placement notebook-ID page
SPECIAL EDUCATION NEEDS OF THIS CHILD
Education notebook-Enrollment Information page
State of California Health and Welfare Agency
Department of Social Services
CWS Case Management System
CP-OHCHEP REV (11/94)
HEALTH AND EDUCATION PASSPORT
May 30, 2016
Confidential in accordance with
Penal Code Section 11167.5 and/or
WIC Sections 827 and 10850
5
GRADE
GRADE LEVEL
PERFORMANCE
Education notebookGrade Level Information
page
TEACHER / COUNSELOR NAME
Education
Education notebook-Grade Level
notebookInformation page
Grade Level
Information
page
EDUCATIONAL NEEDS / SCHOOL PERFORMANCE / STRENGTHS / INTERESTS
Education notebook-Grade Level Information page
!@#$%(7)
PREVIOUS
Education Notebooks for a child that are ‘end dated’ will appear in this section.
SCHOOL NAME
Education Provider notebook-ID page
SCHOOL ADDRESS:
Education Provider notebook-Address page
CONTACT NAME
Education Provider notebook-Contact page
START DATE
Education notebookEnrollment
Information page
HEALTH AND EDUCATION PASSPORT
May 30, 2016
Education notebook-Grade Level
Information page
PHONE
Education Provider notebook-ID page
REASON CHILD LEFT SCHOOL
Education notebook-Enrollment Information page
SPECIAL EDUCATION NEEDS OF THIS CHILD
Education notebook-Enrollment Information page
GRADE
GRADE LEVEL
TEACHER / COUNSELOR NAME
PERFORMANCE
Education
Education notebookEducation notebook-Grade Level
notebookGrade Level Information
Information page
Grade Level
page
Information
page
EDUCATIONAL NEEDS / SCHOOL PERFORMANCE / STRENGTHS / INTERESTS
Education notebook-Grade Level Information page
!@#$%(8)
State of California Health and Welfare Agency
Department of Social Services
CWS Case Management System
CP-OHCHEP REV (11/94)
START DATE
END DATE
Education notebook-Enrollment
Information page
START DATE
END DATE
Education
notebookGrade Level
Information
page
Education
notebookGrade Level
Information
page
Confidential in accordance with
Penal Code Section 11167.5 and/or
WIC Sections 827 and 10850
6